La radiologia medica (2020) 125:365–373

https://doi.org/10.1007/s11547-020-01179-x

CHEST RADIOLOGY

Proposal of a low‑dose, long‑pitch, dual‑source chest CT protocol

on third‑generation dual‑source CT using a tin filter for spectral
shaping at 100 kVp for CoronaVirus Disease 2019 (COVID‑19) patients:
a feasibility study
Andrea Agostini1,2   · Chiara Floridi1,2   · Alessandra Borgheresi2   · Myriam Badaloni2 · Paolo Esposto Pirani2 ·
Filippo Terilli2 · Letizia Ottaviani2 · Andrea Giovagnoni1,2

Received: 9 March 2020 / Accepted: 18 March 2020 / Published online: 1 April 2020
© Italian Society of Medical Radiology 2020

Abstract
Aim  To subjectively and objectively evaluate the feasibility and diagnostic reliability of a low-dose, long-pitch dual-source
chest CT protocol on third-generation dual-source CT (DSCT) with spectral shaping at 100Sn kVp for COVID-19 patients.
Materials and methods  Patients with COVID-19 and positive swab-test undergoing to a chest CT on third-generation
DSCT were included. The imaging protocol included a dual-energy acquisition (HD-DECT, 90/150Sn kVp) and fast, low-
dose, long-pitch CT, dual-source scan at 100Sn kVp (LDCT). Subjective (Likert Scales) and objective (signal-to-noise
and contrast-to-noise ratios, SNR and CNR) analyses were performed; radiation dose and acquisition times were recorded.
Nonparametric tests were used.
Results  The median radiation dose was lower for LDCT than HD-DECT (Effective dose, ED: 0.28 mSv vs. 3.28 mSv,
p = 0.016). LDCT had median acquisition time of 0.62 s (vs 2.02 s, p = 0.016). SNR and CNR were significantly different
in several thoracic structures between HD-DECT and LDCT, with exception of lung parenchyma. Qualitative analysis dem-
onstrated significant reduction in motion artifacts (p = 0.031) with comparable diagnostic reliability between HD-DECT
and LDCT.
Conclusions  Ultra-low-dose, dual-source, fast CT protocol provides highly diagnostic images for COVID-19 with potential
for reduction in dose and motion artifacts.

Keywords  COVID-19 · 2019-nCOV · Dual-source CT · Spectral shaping · Low-dose CT · Chest radiology

Introduction clinical symptoms are fever and cough in addition to other

In December 2019, a pneumonia of unknown origin out-
break in Wuhan, Hubei province (China); the responsible
pathogen was identified as the novel coronavirus (2019-
nCOV), and the related pulmonary syndrome was named
as COVID-19 (CoronaVirus Disease 2019) by the World
Health Organization (WHO) [1, 2]. Common presenting
* Alessandra Borgheresi
alessandra.borgheresi@gmail.com
1
Department of Clinical, Special and Dental Sciences,
University Politecnica delle Marche, Ancona, AN, Italy
2
Division of Special and Pediatric Radiology, Department
of Radiology, University Hospital “Umberto I – Lancisi –
Salesi”, Via Conca 71, 60126 Ancona, AN, Italy
unspecific symptoms including, fatigue, dyspnea, muscle
soreness and headache [3]. Intriguingly, a small percentage
(5%) case is asymptomatic (i.e., with normal body tempera-
ture or minor discomfort) [4, 5], while reverse-transcription
polymerase chain reaction (RT-PCR) from swab samples
has demonstrated high specificity but relatively low sen-
sitivity (60–70%) [6, 7]. Moreover, when comparing RT-
PCR to chest CT, the latter demonstrated a better sensitivity
in particular in early stages [6, 7]. Therefore, the RT-PCR
from swab samples is still the standard of reference in the
diagnosis of COVID-19, while unenhanced, high-resolution
chest computed tomography (CT) has a central role in detec-
tion, diagnosis and follow-up of the disease [8–10].
CT is a widely available technique allowing for high-
quality and standardized evaluation of the lung parenchyma.

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366
However, radiation exposure and motion artifacts are major
issues in uncooperative, young patients undergoing to
repeated CT examinations [11]. To reduce motion artifacts
in uncooperative patients (e.g., pediatric patients or patients
with dyspnea), fast acquisitions are obtained by lowering the
rotation time of the tube-detector system with high pitch and
wide collimation values [12]. Conversely, lower radiation
doses are achieved at low kV with the implementation of
iterative reconstructions for noise reduction [13]. The dual-
source CT scanners (DSCT, Siemens Healthineers, Erlan-
gen, Germany) are equipped with two asymmetrical tube-
detector systems (i.e., different scan Field of View, FOV),
mounted in the gantry with an offset of ~ 90°. The two tube-
detector systems work at different kVp settings for dual-
energy acquisitions or at the same kVp setting for ultrafast
acquisitions at long pitch (Pitch 1.5–3, Flash or Turbo Flash
mode, Siemens Healthineers, Erlangen) [14, 15]. Moreover,
the X-ray tubes in the second- and third-generation scan-
ners (respectively, the Somatom Flash and Force, Siemens
Healthineers, Erlangen) have additional tin filtration [16,
17]. In particular, the more aggressive tin filtration in the
Somatom Force provides the best spectral separation in
dual-energy (DECT) acquisitions by increasing the mean
energy of high-kVp spectrum (i.e., 150Sn kVp) [17]. More-
over, the spectral shaping with tin filter (i.e., 100Sn kVp)
allows for reduction in the low-energy component of the
X-ray spectrum, leading to significant dose reduction [18,
19]. Coupling an ultra-low-dose, fast, long-pitch dual-source
acquisition with spectral shaping may be of relevant value
in serial evaluations in dyspneic or coughing patients with
COVID-19.
The aim of this work is to test the feasibility, with subjec-
tive and objective analysis, of an ultra-low-dose, fast, long-
pitch, dual-source acquisition on third-generation DSCT
(Somatom Force, Siemens Healthineers, Erlangen) for the
lung evaluation in patients affected by COVID-19 related
pneumonia.
Materials and methods
Ethical standards
This study was approved by the local Ethical Board, and the
informed consent was not collected in written form because
of the specific disease.
Patient population
Inpatients > 18  years old, positive for COVID-19 of
the upper respiratory tract swab from the Division of
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La radiologia medica (2020) 125:365–373
Infectious Disease, referred to the Department of Radiol-
ogy for a chest high-resolution CT between Feb 24, 2020
and March 4, 2020, with no basal chest X-ray performed,
were prospectively included to be scanned on the third-
generation DSCT (Somatom Force, Siemens Health-
ineers). Anamnestic and clinical information were col-
lected. Patients with pneumonia other than COVID-19, or
with contraindication to CT were excluded.
Image acquisition and reconstruction
The imaging protocol on the third-generation DSCT
(Somatom Force, Siemens Healthineers, Erlangen) was
composed by a spiral high-resolution dual-energy acqui-
sition (HD-DECT) and by an ultra-low-dose acquisition
(LDCT) in deep inspiration when possible; no contrast
material was administered. Since COVID-19 pathologi-
cal mechanism is not completely understood, and other
strains of coronavirus family demonstrated similar pul-
monary syndromes with development of fibrosis (i.e., air
trapping); the first three patients were evaluated also with
an ultra-low-dose, fast scan in deep expiration [20, 21].
A relatively fast DECT, spiral, caudocranial acquisi-
tion (HD-DECT) was set with the following parameters:
90/150Sn kVp, modulated mA (CareDose 4D, Siemens
Healthineers, Erlangen, Germany) with reference 85 mAs,
rotation time 0.25 s, a relatively long pitch of 1.1 and a
wide collimation (2 × 192 × 0.6  mm). In the ultra-low-
dose, fast acquisition (LDCT), both the tubes worked at
100 kVp with 0.6-mm tin filter (100Sn kVp), with a wide
collimation (2 × 192 × 0.6 mm), a rotation time of 0.25 s,
an ultra-long pitch (pitch = 3, TurboFlash mode, Siemens
Healthineers), with modulated mA at 180 mAs reference.
Both the HD-DECT and LDCT datasets were recon-
structed with the available iterative reconstruction algo-
rithm ADMIRE, Strength 4 (Advanced Modeled Iterative
Reconstruction, Siemens Healthineers, Erlangen). The
lung parenchyma was reconstructed with sharp kernels
(HD-DECT: Bl64; LDCT: Bl57), with linear blending of
0.7 at slice thickness/spacing of 1.5/1 mm and a window/
level of 1200/-600 HU (named Lung Images, LUNG). The
mediastinal structures were evaluated with softer kernel
(Br40 for both acquisitions) with linear blending of 0.7,
slice thickness/spacing of 3/1.5 mm and a window/level of
350/50 HU (named Mediastinal Images, MED). Sagittal
and coronal reconstructions were obtained.
DECT datasets were reconstructed with different linear
blending ratios (Blending Ratio 0.2) in order to reduce
beam-hardening artifacts in uncooperative patients on a
dedicated workstation (Syngo.via VA20, Dual Energy,
Siemens Healthineers, Erlangen).
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Radiation Dose evaluation and Acquisition Time
The CT dose index (CTDIvol) and dose length product
(DLP) for each scanned patient were recorded. The effec-
tive dose (ED) was calculated using a conversion factor
(k) of 0.0145 mSv × mGy−1×cm−1 for 120 kV according to
Deak et al. [22] based on the following formula:
ED = DLP × k
Finally, the acquisition (exposure) times for HD-DECT and
LDCT were recorded.
Subjective image analysis
Two independent radiologists with 15 and 10  years of
experience evaluated the quality of the CT images on a
PACS workstations (Picture Archiving and Communica-
tion System; Centricity Radiology, GE Healthcare, Mil-
waukee), after removing personal and technical data from
the images. The lung parenchyma and airways were eval-
uated on Lung Images, while the mediastinal structures
(e.g., lymph nodes) were evaluated on the Mediastinal
Images, in HD-DECT and LDCT.
The subjective analysis was performed by using
5-points Likert scale and included three sections: general
quality of the image (mediastinum and lung images), ana-
tomical structures (lung images), pathological findings
(lung or mediastinal images).
The evaluation of general quality included the following
parameters and scales:
1. Sharpness, where sharpness was rated as: 1 = unaccep-
table, 2 = significantly reduced with blurring of adja-
cent structures, 3 = minimally reduced sharpness with
blurring of adjacent structures, 4 = sharpness minimally
reduced, 5 = excellent sharpness;
2. Perceived image noise: 1 = unacceptable, 2 = above aver-
age, 3 = average image, 4 = less than average, 5 = mini-
mal;
3. Motion artifacts: 1 = unacceptable, non-diagnostic;
2 = marked; 3 = mild; 4 = minimal; 5 = no motion arti-
facts
4. Subjective diagnostic reliability: 1 = no diagnostic sig-
nificance; 2 = poor; 3 = fair; 4 = good; 5 = optimal diag-
nostic reliability;
5. Overall image quality, including other artifacts—beam-
hardening artifacts: 1 = unacceptable, 2 = fair, 3 = mod-
erate, 4 = good, 5 = excellent.
The evaluation of anatomic structures included the
parameters:
1. Major anatomical structures (fissures and small vessels);
2. Small anatomical structures (bronchi < 2 mm and sep-
tae);
In both cases, the Likert scale was defined as follows:
1 = unacceptable (landmarks not visible); 2 = poor (< 25%
landmarks visible); 3 = fair (25–75% landmarks visible);
4 = good (> 75% landmarks visible); 5 = excellent (all
landmarks visible).
Finally, a third radiologist (10  years of experience)
detected main lung pathological findings related to
COVID-19 on HD-DECTLUNG and HD-DECTMED images
and the other two radiologists were asked to evaluate
the same finding on the ultra-low-dose acquisitions, in
particular:
1. Ground glass opacities (GGO) (< 20 mm);
2. COVID-19 signs, e.g., reverse halo/crazy paving;
3. Centrolobular nodules;
4. Consolidations (segmental–subsegmental);
5. Lymph nodes (on HD-DECTMED);
The relative Likert scale was set as follows: 1 = finding
not detected; 2 = barely detected, unreliable interpretation;
3 = visible finding with marked blurring and uncertain
interpretation; 4 = visible finding, blurred, with no influ-
ence on diagnosis; 5 = finding clearly visible with good
demarcation.
Objective image analysis
Signal-to-noise ratio (SNR) and contrast-to-noise ratio
(CNR) were evaluated by the third radiologist (10 years of
experience) by placing 1 ± 0.05 cm2 circular Region of Inter-
est (ROI) for the following structures:
1. SNR:
a. HD-DECTLUNG and L ­ DCTLUNG: lung parenchyma,
trachea and muscle and subcutaneous fat;
b. HD-DECTMED and ­LDCTMED: trachea, descending
aorta, paraspinal muscle, subcutaneous fat;
2. CNR (the selected reference was the subcutaneous fat):
a. HD-DECTLUNG and L ­ DCTLUNG: lung parenchyma,
trachea, paraspinal muscle;
b. HD-DECTMED and L ­ DCTMED: descending aorta,
trachea, paraspinal muscle.
SNR and CNR were calculated considering average and
standard deviation (SD) of the HU from the placed ROI as
follows [13]:
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368 La radiologia medica (2020) 125:365–373

|Average HUAnatomical Structure | Results

SNR = | |
SDAnatomical Structure
Patient Population and radiological findings on CT
|Average HUAnatomical Structure − Average HUfat |
CNR = | | In this study were included 10 patients (M/F = 7/3) with a
SDfat median age of 53 (IQR: 47–83) and a median BMI of 28
(IQR: 26–30). Two of 10 patients (20%) had a BMI > 30
and 3/10 (39%) had severe symptoms (Temperature > 38 °C,
dyspnea and respiratory failure) and were not able to main-
Statistical analysis
tain the arms raised during the CT examination. The radi-
ological findings of each patient at presentation are sum-
Quantitative parameters were expressed as median and
marized in Table 1 and are comparable to those previously
interquartile ranges (25–75 p, IQR). Qualitative and quan-
reported [8].
titative parameters were compared with nonparametric
tests (Wilcoxon for paired samples). A dedicated statistical
Radiation dose and acquisition time
software was used (MedCalc v19.1.6, MedCalc Software,
Ostend, Belgium).
Table 2 summarizes the applied radiation dose and acquisi-
tion time. Statistically significant differences were found in
radiation dose and acquisition times. The use of spectral
shaping at 100 kV (100Sn kVp) allowed for a significant
reduction in ED, with a median dose reduction of 90.6%
(− 88.35 to − 91.12%).

Objective image analysis

Table 1  Main radiological findings in 10 COVID-19 positive patients
Radiological finding Number of The results of the objective image quality analysis are shown
patients: 10 in Table 3. Statistically significant differences were found in
SNR and CNR, with higher values in HD-DECT images, for
Ground glass opacities 10 (100%)
different anatomical structure with exception of lung paren-
Multiple and Bilateral 10 (100%)
chyma (p > 0.05).
with consolidation 7 (70%)
Linear opacities 7 (70%)
Subjective image analysis
Rounded opacities 2 (20%)
Peripheral involvement 10 (100%)
The results of the subjective image evaluation assessment
Central parenchyma involvement 1 (10%)
are summarized in Table 4. On the basis of the average
“Crazy-Paving” pattern 3 (30%)
Likert scale, the two radiologists assessed for the over-
“Reverse Halo” Sign 2 (20%)
all subjective image quality a median point value of 4
Bronchial Wall Thickening 5 (50%)
for both the protocols. As expected, the subjective image
Bronchiectasis 4 (40%)
noise had a trend to be worse in the LDCT. However,
Lymphadenopathy 0
the LDCT demonstrated a significant reduction in the
Bilateral lung involvement 9 (90%)
motion artifacts when compared to the standard DECT
> 2 lobes affected 8 (8%)
(4 vs. 5) (Fig. 1a, b). Nevertheless, in terms of diagnostic
Air trapping 0

Table 2  Radiation dose and HD-DECT median (25 - 75 p) LDCT median (25 - 75 p) P*

exposure times
CTDIvol (mGy) 6.38 (3.91–7.51) 0.64 (0.47–1.12) 0.016
DLP (mGy × cm) 226.21 (176.01–322.03) 19.5 (17.5–29.02) 0.016
ED (mSv) 3.28 (2.55–4.67) 0.28 (0.25–0.42) 0.016
Exposure time (s) 2.02 (1.81–2.36) 0.62 (0.54–0.72) 0.016

CTDI CT dose index; DLP dose length product; ED effective dose

*Wilcoxon test for paired samples

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Table 3  Objective image analysis: signal-to-noise (SNR) and contrast-to-noise (CNR) ratios

HD-DECTLUNG LDCTLUNG P* HD-DECTMED LDCTMED P*
Median Median Median Median
(25–75 p) (25–75 p) (25–75 p) (25–75 p)

SNR
Descending aorta // // – 4.06 (3.44–5.51) 1.84 (1.72–2.22) 0.016
Lung parenchyma 13.49 (12.76–17.48) 12.2 (9.83–14.21) 0.578 // // –
Trachea 24.52 (16.67–40.29) 19.9 (14.33–20.84) 0.219 29.38 (12.64–94.91) 41.93 (19.34–56.52) 0.038
Subcutaneous fat 2.37 (1.34–2.67) 0.98 (0.93–1.22) 0.016 10.53 (9.85–12.15) 4.82 (4.43–6.03) 0.016
Muscle 0.65 (0.46–0.77) 0.44 (0.25–0.52) 0.016 3.83 (1.13–4.14) 1.7 (0.82–2.25) 0.047
CNR
Descending aorta // // – 14.35 (12.93–16.29) 6.66 (6.11–8.61) 0.016
Lung parenchyma 15.63 (8.48–18.89) 7.54 (76.82–9.68) 0.057 // // –
Trachea 17.4 (9.35–20.21) 8.21 (7.56–10.29) 0.047 78.68 (73.25–93.24) 40.70 (35.17–53.28) 0.016
Muscle 3.00 (1.72–3.87) 1.48 (1.33–1.74) 0.016 15.21 (11.81–15.42) 7.18 (6.56–7.26) 0.016

Table 4  Subjective image HD-DECT LDCT P*

analysis with Likert scales (see Median (25–75 p) Median (25–75 p)
text)
General evaluation
Image sharpness 4 (4–4) 4 (4–4) –
Additional image noise 4 (4–5) 4 (3–4) 0.063
The presence of motion artifacts 4 (2–4) 5 (5–5) 0.031
Subjective diagnostic reliability 5 (4–5) 5 (4–5) –
Overall diagnostic image quality 4 (4–5) 4 (4–5) –
Anatomy
normal lung structures (major fissures and small vessels) 5 (5–5) 5 (4–5) –
bronchi (< 2 mm diameter) 5 (4–5) 5 (4–5) –
Parenchymal findings
GGO < 2 cm Reference standard 5 (4–5) //
COVID signs (Crazy paving—reverse Halo sign) Reference standard 5 (4–5) //
Centrolobular nodules Reference standard 3 (3–4) //
lobar/subsegmental consolidations Reference standard 5 (4–5) //
Lymphadenopathy Reference standard 4 (4 –5) //

Median values on the Likert scale (from 1 unacceptable to 5 excellent) for the two readers
* Wilcoxon test for paired samples
– Unable to calculate p
// Test not performed

performance the radiologist did not experience a signifi- Discussion

cant reduction in diagnostic reliability and evaluation
of the pathological findings between the two protocols
(Fig. 2a–c).
Finally, post-processing of DECT datasets at different
blending ratio allowed for reduction in beam-hardening
artifacts in 1/10 (10%) patients who was unable to main-
tain the arms raised (Fig. 1c–f). The beam-hardening arti-
facts minorly affected the 100Sn kV.
In the present study, we included a small sample of
patients affected by COVD-19-related pneumonia with
variable clinical and radiological manifestation of the
disease, and comparable findings described in the litera-
ture [8, 9]. Given the etiological and clinical similarities
between COVID-19 and other pulmonary syndromes such

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370 La radiologia medica (2020) 125:365–373

Fig. 1  Technical advantages of DECT and LDCT. Axial images, a, c, ening artifacts. c, e have a linear blending of 0.7 while D, F have lin-
d, e, f: HD-DECT; b: LDCT, lung kernel. a, b Comparison of HD- ear blending of 0.2 resulting in reduction in artifacts in mediastinum
DECT and LDCT, demonstrating the reduction in the motion artifact (d) and left lung parenchyma (f)
in the LDCT. c–f Shows the role of DECT in reduction in beam-hard-

as SARS and MERS (which demonstrated the development results and thus not investigated any more. Further studies
of air trapping and fibrosis [21]), the presence of air trap- on follow-up of COVID-19 should be performed to clarify
ping was searched in the first three cases, with negative possible chronic lung injuries.

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Fig. 2  COVID-19 Pathological Findings: HD-DECT versus LDCT. Axial Images. a, c HD-DECT; b, d LDCT. a, b Good demonstration of
crazy-paving both in a and b. c, d demonstration of Reverse Halo and linear opacities in HD-DECT and LDCT

In these 10 patients with COVID-19, we evaluated the
feasibility of an ultra-low-dose, long-pitch, dual-source,
fast CT acquisition to be implemented for serial follow-up
examinations in symptomatic patients with COVID-19. At
baseline, a DECT acquisition was chosen as internal refer-
ence standard.
Previous studies in the literature demonstrated significant
dose reduction with spectral shaping in chest CT, achiev-
ing a dose comparable to a chest x-ray examination [12, 13,
18, 19, 23, 24]. In our population, the effective dose of the
ultra-low-dose, long-pitch, dual-source fast acquisition was
comparable to the values reported in previous studies and
close to a chest X-ray examination. In these patients, chest
X-ray examination at baseline was not performed to avoid
unnecessary radiation exposure.
The rationale behind the DECT choice was to couple a rela-
tively fast acquisition (2–2.5 s) with the possibility of post-
processing for eventual artifact reduction with different blend-
ing combinations in uncooperative patients unable to maintain
arms raised. The post-processing of DECT datasets reduced
beam-hardening artifacts in 1/10 patients (10%). These arti-
facts minorly affected the LDCT. An explanation of this can

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372
be found in the relatively high mean energy of the 100Sn kVp
spectrum [19].
Conversely, the LDCT acquisition was conceived to avoid
artifacts from heart beats, breathing and coughing in patients
with severe symptoms, which was significantly demonstrated
in the subjective analysis (Table 4, Fig. 1). The feasibility, the
quality and the diagnostic performance of ultra-low-dose chest
CT with spectral shaping, and other technical solutions have
already been demonstrated [12, 13, 18, 19, 24] sometimes with
questionable results about the pathological findings [25]. To
our knowledge, this is the first study evaluating a long-pitch,
dual-source acquisition with spectral shaping in acute setting
in patients with COVID-19. As expected from a low-dose
acquisition, the LDCT images had trend, though poorly signifi-
cant, to be evaluated as more noisy than the HD-DECT images
(Table 4). However, it did not significantly influence the detec-
tion and characterization of main anatomical and pathological
pulmonary findings in this subset of patients, as demonstrated
by the high rankings (Likert ≥ 3 for the pathological findings
in Table 4) (Fig. 2).
The quantitative analysis found significant differences in
SNR and CNR for several anatomical structures, as expected
when comparing a standard-dose and an ultra-low-dose acqui-
sition with an ultra-long pitch. However, these differences had
poor significance in the evaluation of lung SNR and CNR,
in agreement to the subjective analysis. Again, this can be
explained by considering the relatively high mean energy of
the 100Sn kVp spectrum contributing to lowering the noise
together with the radiation dose (Table 2, Fig. 2) [19]. More-
over, in this protocol, the reconstructions have been kept as
similar as possible, in particular the slice thickness, the slice
spacing and the iterative reconstructions while for LDCT a
slightly softer kernel was used. Again, in Table 4, the image
sharpness of LDCT was comparable with maintained diag-
nostic reliability. Further studies are necessary to fully explore
the role of iterative reconstructions at lower doses in this acute
setting [18].
The study has several limitations. It is a single-center study
with a small population to evaluate the feasibility of a low-dose
CT protocol in acute setting. The small size of the sample did
not allow for more sophisticated statistical analysis, such as
inter-reader agreement or the relation between BMI, radiation
dose and image quality.
Concluding, a compromise including preserved image
sharpness within lung parenchyma, with minimally blurred
mediastinal structures in the face of a median dose reduction
of more than 90% may be acceptable when performing serial
CT controls in severely ill young patients [26].
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La radiologia medica (2020) 125:365–373
Conclusions
The study demonstrated the feasibility of an ultra-low-
dose, fast chest CT acquisition with spectral shaping at
100 kVp (100Sn kV) and dual-source acquisition with
ultra-long pitch (Turbo Flash, Siemens Healthineers) in
patients affected by COVID-19 with good diagnostic reli-
ability and potential for reduction in radiation dose and
motion artifacts.
Funding  This study was not supported by any funding.
Compliance with ethical standards 
Conflict of interest  A.A. is a speaker for Siemens Helthineers. The oth-
er authors declare that they have no conflict of interests.
Ethical approval  All procedures in studies involving human partici-
pants were in accordance with the ethical standards of the institutional
and/or national research committee and with the 1964 Declaration of
Helsinki and its later amendments or comparable ethical standards.
Informed consent  For this type of study, formal consent is not required.
Consent for publication  For this type of study, consent for publication
is not required.
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